More than Just a Fall

Monday, June 6, 2011
Dennis Edgerly, EMT-P

It’s 45 minutes before shift change. It’s been a long night, and before your relief arrives, your ambulance is dispatched to the report of an elderly fall patient. You and your partner release a collective sigh as you move to the ambulance and acknowledge the call and announce your response. When you arrive on scene, you’re met by a woman in her late 50s telling you she found her 73-year-old mother lying on the floor this morning, unable to get up. The daughter states that she spoke with her mother two evenings ago to confirm their breakfast plans for this morning and everything sounded fine.

The patient is awake and breathing and responds to your questions, but she’s lethargic and confused about the time of day and recent events, which the daughter adds is abnormal behavior. She’s dressed in a nightgown and tells you she hurts everywhere and wants to get into bed.

It’s important for providers to remember that what may appear to be a simple fall has many other factors that should be considered.

Assessing Geriatric Falls
Falls in geriatric patients can result in traumatic injuries that are not commonly seen when a younger person falls such as hip fractures and pelvic fractures. Fractured ribs may cause damage to the lungs and the liver, so they must be considered as well. After evaluating and correcting problems with vital function, such as breathing and circulatory status, you need to consider underlying causes and associated events. When a patient is found on the ground, EMS providers must ask themselves: How did the patient get there?

Causes of falls in geriatric patients can be simplified into two primary categories: trip and fall or pass out and fall. These two mechanisms have different implications. When evaluating a trip and fall, EMS providers should focus on the injuries the trauma of the fall may have caused. In the case of a pass out and fall or syncope, EMS providers must consider the possible medical causes in addition to the traumatic injuries resulting from the fall.

Common causes of syncope include strokes or transient ischemic attacks, hypoperfusion to include slow hemorrhage and dehydration, medication side effects or interactions and cardiac dysrhythmias, such as new onset atrial fibrillation and high-degree heart blocks. If the patient is having or has had a stroke or heart attack, the EMS provider on scene must consider the implications of treating the underlying cause and the potential effects that treatment will have on any new injuries the fall causes. For example, a patient experiencing a heart attack would benefit from aspirin and nitroglycerin, but if the fall caused an injury that was bleeding substantially, both of these treatments would be contraindicated.

The next factor that must be considered is time (i.e., how long the patient has been on the ground.) Time affects many things. Geriatric patients commonly have difficulty regulating body temperature, and lying on the floor for any amount of time won’t help. It’s key to remember that conduction is the exchange of heat between two objects in contact with each other. In other words, being in constant contact with an object that’s cooler than a patient’s body temperature, such as a floor, will begin to drop body temperature. Hypothermia must be considered in patients who’ve been on the floor for a prolonged time. Hypothermia can cause an alteration in mentation and can adversely affect the body’s ability to clot if a patient is bleeding.

EMS providers know from experience that many geriatric patients take several drugs a day to treat a variety of chronic illnesses. If a patient has been on the floor for a prolonged period of time, there’s a good chance they haven’t taken their prescription medications. Non-compliance with medications, even for a short period of time, can result in exacerbation or worsening of medical conditions: blood glucose levels can rise or drop, blood pressure can increase causing stroke, and patients with heart failure can have an increase of pulmonary edema, resulting in hypoxia. All these conditions can alter mental status.

When tissue is compressed for a prolonged period of time, damage to the superficial tissue in the form of ulcerations and skin tears can occur. The underlying muscles can be affected too, and such conditions as compartment syndrome can occur. A sign of compartment syndrome includes pain out of proportion to injury. So if your patient is complaining of horrible pain, but you don’t see signs of obvious injuries, consider compartment syndrome.

Conclusion
When you see a geriatric patient lying on the floor, consider underlying complications. In some instances, the call is as easy as helping someone back to bed. In other cases, it can be much more complicated. Always consider potential underlying causes. Never accept a new presentation of altered level of conscious in a geriatric patient as OK because the patient is “old.” And, don’t be too quick to rule out geriatric abuse. Thorough assessment of the patient, scene and situation allows for complete treatment and helps prevent negative outcomes.